This document is a clinical assessment form for nursing students containing sections to document a patient's personal information, chief complaint, history of present illness, past medical history, family history, social history, occupational history, review of body systems, laboratory investigations, medications/treatment, and nursing care plan. The form collects information about a patient's name, gender, age, diagnosis, vital signs, allergies, drug use, alcohol use, smoking habits, and assessments of their general health and specific body systems to guide nursing students in developing an appropriate care plan.

1. Prepared by Muhammad ShahidVice Principal IIN Page 1 of 4
Ilmiya Institute of Nursing
Clinical Assessment form for 1st year and 2nd year General Nursing
Name of Patient:__________________________ Gender:_____________ Age:_____________
Marital Status:___________ Contact / Cell #: ____________ Occupation:______________________
Address:____________________________ Medical Diagnosis:_______________________________
Date of admission: _______________ Department/Ward:_____________________________
Chief Complain:
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Historyof PresentIllness:
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Past Medical History:
 Allergies:
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 Drug history:
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 Alcohol:
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 Smoking:
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FamilyHistory:
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Social History:
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Occupational History:
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Reviewof Systems(ROS):
1. General:
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2. Vital sign:
Temperature:_________ Pulse:________ Respirations:_________ BloodPressure:_________
3. Skin:
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Head:

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4. Eyes:
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5. Ears:
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6. Nose:
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7. Throat:
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8. Respiratory:
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9. Cardiovascular:
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10. Gastrointestinal:
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11. Genitourinary:
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12. Central NervousSystem:
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13. Musculoskeletal System:
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Laboratory Investigations:
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Medications/Treatment:
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NursingCare:
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Name of Student:___________________________ Class:______________________
Name and Signature of Clinical Instructor/HeadNurse /Staff Nurse:________________________
Date: ________________________
Time:________________________